HomeMy WebLinkAbout09-30-13 � rcesez
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PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF CU c� ,� �r l a r2� COUNTY, PENNSYLVANIA
Petitioner(s) named below, who is/are 18 years of age or older, apply(ies) for Letters as specified below, and in
support thereof aver(s)the following and respectfully request(s)the grant of Letters in the appropriate form:
Decedent's Information r� c.=y
Name: �✓I cx t S c�� J ��f f� File No: tl � - � � - �L1� /
a/k/a: (Assigned by Register)
a/k/a:
a/k/a: Social Security No: J g�' C�-���v�
Date of Death: Age at death: 2
Decedent was domiciled at death in G U� b �r ( u K c�- County, �� (Srare)with his/her last
principal residence at 'Z32 3c�, (�o�c�, cl, J7 2SrJ Sc�utk(�vvr P -�ov� Guwt be r Lc�n �
Street address,Po t Office and Zip Code City,Township or Borough County
Decedentdiedat���'k. �—�4S(� ifci � ydrk ���'�"� �1�
Street sddress,Post ffice and Zip Code City,Township or Borough County State
Estimate of value of decedent's property at death:
If domiciled in Pennsylvania.. ...... . . . . . . ....... . . .. . .. All personal property $
If not domiciled in Pennsylvania. . . . . ..... . . . . . . . ....... Personal property in Pennsylvania $
If not domiciled in Pennsylvania. .. . . ....... . . . . . .. ..... Personal property in County $
Value of real estate in Pennsylvania.. . . .. .... . . . . .............. . . . . . . . . . . .... . . ... .. . . . . .. . . $
TOTAL ESTIMATED VALUE. . . . $ 0.00
Real estate in Pennsylvania situated at:
(Attach additional sheets,if necessary.) Street address,Post Office and Zip Code City,Township ar Borough County
� A. Petition for Probate and Grant of Letters Testamentary
Petitioner(s)aver(s)he/she/they is/are the Executor(s)named in the last Will of the Decedent,dated and Codicil(s)
thereto dated
State relevant circumstances(e.g.renunciation,death of executar,etc.� ._ � "':"l
� � .,
Except as follows: after the execution of the instrument(s)offered for probate Decedent did not marry,was uat d�vorced,wa§not a party�o a pending
divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3�i(`.�-�,��d did not have a child born or
adopted;and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. r-- ��_ � c^-• : �
�NO EXCEPTIONS �EXCEPTIONS � �°�� " '
..:. �, -
� B. Petition for Grant of Letters of Administration (If applicable) ' ��:. _-l
c.t.a.,d.b.n., d.b.n.c.t.a.,pendente l�te du��nte abseniia, durante minoritate
- ' �:;
If Administration,c.t.a. or d.b.n.c.t.a., enter date of Will in Section A above and Ftrmplete li��f heirs:��
Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds for divorce had been established as defined
in 23 Pa.C.S. §3323(g)and was neither the victim of a killing nor ever adjudicated an incapacitated person.
�NO EXCEPTIONS � EXCEPTIONS
Petitioner(s),after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse(if any)and heirs(attach
additiona!sheets, if necessary):
Name Relationshi Address
�<s� J ��rr- r au � -�e �- S�� e�sb��r P�} /7Z�
FormRW-02 .�. ioil�izor� Page 1 of 2�4
. , Oath of Personal Representative Official Use Only
COMMONWEALTH OF PENNSYLVANIA }
} SS:
COUNTY OF Cu� �L�'�a�� }
Petitioner(s)Printed Name Petitioner(s)Printed Address
C�(� r�s (-�. �e �rr 3� ►'�lon �m� /'�v�..Sl�� E�sbu� f� /�7 ZS
The Petitianer(s)above-named swear(s)or affirm(s)the statements in the foregoing Petition are true and correct to the best of the knowledge and belief
of Petitioner(s)and that,a�Personal Representative(s)of the Decedent,the Petitioner(s)will well and truly administer the estate according to law.
Swom to or��ffirmed und subscribed before � � �b r�-'�-^^'� Date � �3o /�i7
me this � day of � `1 �1', �C�1� Date
By: � � ( Date
For the Register Date
BOND Required: Q YES �TO To the Register of Wills:
FEES: Please enter my appearance by my signature below:
Letters . . . . . . . . . . . . . . . . . . . . . . $ oC-l-'. �fi'' Attorney Signature:
( '?j ) Short Certificate(s). . . . . . � �-(`��
( ( )Renunciation(s).. . . . . . . . � .L`�c�',`
( ) Codicil(s). . . . . . . . . . . . .
( )Affidavit(s).. . . . . . . . . . .
Bond.. . . . . . . . . . . . . . . . . . . . . . . Printed Name:
Commission. . . . . . . . . . . . . . . . . . Supreme Court
Other . . . . . . . ID Number:
� C . . . . . . . . l 5.�^t'!
" ` . . . . . . . . ���. � Firm Name:
. . . . . . . . Address:
. . . . . . . . Phone:
Automation Fee. . . . . . . . . . . . . . . r�. t'L, Fax:
JCS Fee. . . . . . . . . . . . . . . . . . . . . r',1 3 SV Email:
TOTAL. . . . . . . . . . . . . . . . . . . . . $ ��.SCD-66"
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Form RW-02 rev.10/I1/2011 Page 2 of 2
Oath of Personal Representative ors�;a�vs�o��y
COMMONWEALTH OF PENNSYLVANIA } ',
} SS:
COUNTY OF } ',
,,
titioner(s)Printed Name Petitiouer(s)Printed Address '
�
,
,
The Petitioner(s)above-named swear(s)or af i (s)the statements in the foregoing Petition are true d correct to the best of the knowledge and belief
of Petitioner(s)and that,as Personal Representati s)of the Decedent,tlie Petitioaer(s)will we and truly administer the estate according to law.
Sworn to or affirmed and subscribed before Date
me this day of , Dace
By: Date
For the Register Date
� `._� i ( .
BOND Required:�YES �NO o the Re 'ster of Wi![s: �
FEES: Please enter appearance by rtt�7si�t�ature belo�w: �
�
Letters . . . . . . . . . . . . . . . . . . . . . . $ Attorney Signature: � �'' ' �
�� �`'��� �� ,
( ) Short Certificate(s).. . . . . �; C!> �,::_
( )Renunciation(s).. . . . . .. . ~�V� � y`
.:� �-�� •
( )Codicil(s). . . . . . . . . . . . . _� .. _�,
� )Affidavit(s).. . . . . . . . . . . ,,^� �.._ ; _
� f.... ;.._. - �...
Bond.. . . . .. . . . . . . . . . . . . . . . . . Printed Name: �.. —� " ,.
_,.
Commission. . . . . . . . . . .. . . .. :. Supreme Court y> �,J -'i
Other . . . . ID Number:
. . . . . . . . Firm Name:
. . . . . . .. Address:
. . . . . . .. Phone:
Automation ee. . . . . .. . . .. . . . . Fax:
JCS Fee. . . . . . . . . . . . . . . . ... . . Email:
TOT . . . . . . . . . . . .. . . . . . . . . $
DECREE OF THE. REGISTER
� � �I -I ?�' �l.�.��'
Estate of�� � File No: _
a/k/a:
AND NOW, �j���� �f'��.(l1��.� , ���� , in conside�ation of the foreg ing Petition,
satisfactory proof having been pres�e►ted before me,IT IS ECREED that Letters �� m j��S�'1`�('� � (�'y1
are hereby granted to e �'l
in the ab ve estate and(if applicable) that
the instrument(s)dated
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil�s))of Decedent. ry
��. � � � � Il,� , ��, � � S�. L L,
Register of Wills �� � ����d����,� . � , � __, �
Fo,�,�,irw-nz ,��v. lnirrizn�i � Pa e 2 of
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H105.80i REV(9/11)
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
;�- •-
Fee for this certificate, $6.00 ��. � � � - ��� ,�����"""-�-..., This is to certify that the information here given is
r _ � � ,,�'''���,P��H�F Pfiy,�;=_ correctly copied from an original Certificate of Death
I l S��1� _ . :i v i . , ._� � P�1 � - f
�,��c,� ���� duly filed with me ns Local Registrar. The original
n `�� ;�` � \�� certificate will be "forwarded to the State Vital
��'� �Z r � 3;J � ' '�'� � z;
���;� ���� ,i� ,�.5 �� ;v� yb� ia� Records Office tior e� na t filing.
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P 19 0 � 7 8 8 9 �� , _ - � ;��,.-_..._._ ._ .__._ _
�r�i� l::� ='O9q���,P�'��'� �� �
't�HANS' C�J�7`: -.MENtOF ,��'''�,
Certification Number . ""�����°""�� Loc Re�istrar Date Issued
GIJ�lBERLAND C�., Pq -
Type/Print In COMMONWEALTH OF PENNSVLVANIA�DEPARTMENT OF HEALTH�VITAL RECORDS
Pertnsnent
Black Ink CERTIFICATE OF DEATH State Ffle Number:
1.Decetlent's Legal Name(Flrsi,Middle,45t,Suffix) 2.Sex 3.Soclai Security N�mber 4.Oate of Dealh(MO/Day/Yr)(Speli Mo)
Madison J.PERRY Male '186-70-8853 January�O,20'13
Sa.P.�e-Las[Birthday(Yrs) Sb.V nde�1 Yesr Sc.Under 1 Da 6.Date M BiKh(MO/Oay/Vesr)(Spell Month) 7a.BlrChplace(City entl State or Foreign Country)
Months Days Mo�rs Minu(es C8�I16�0
24 June 30,1988 7b.Birthplace(COUntyj Cumberland
8a.Residenee(Steie or Forelgn Country) 8b.Resltlmce(Streetand Number-Inclutle Apt No.) 8c.Oltl Decetlenc Llve In a Townzhip7
P'�' 232 Big Pond Road �Yes,decedent Ilvetl In Southampton i,�,P.
Sd.Residence(GOUnty) �
Cumbarland ge.Resldence(Zlp Cotle) �7257 ��NO,tl�ceAenS Ilved wifhin Iimita of city/boro.
9.Ever In US Armed Forces7 10.Marlt'al Status at Time of Death 0 Mamletl � Widowed 11.Survlving Spo�se's Name(If wife,give name prior to first marriage)
�V<s �No �Unknown 0 Diwrced J$[Never M�rrled 0 Unknow
12.F�[her'a Name(First,Middle,Last,Sufflx) 13.Methe�'s Name PAOr to First Mar�lage(Firs[,Mltldle,LasC)
Chris P.Perry � Lei Lani D.Gribbie
14a.Informent's Name 14b.HelwHOnzhlp to Decedent 14c.InfortnanS's Malling AGOross(Street anC Number,Ciiy,State,21p Cotlej
s Lei Lani D.Vaughn `', Mother 232 Big Pond Road Shippensburg PA�7257
......................................................».. ........................ ...... eat heck onl o
¢ If Desth Occurretl in a Hos Ital: In �...... .......l..e:...a.�.�"....... .........Y..ne.............................. ......""""""'"'�.............yy .....
"'""'' .............................. .
, P Pstivnt �If Death Oct�rretl Somewhere OMer Than a Hozpllsl: �Hosplce Facill LJ Decedent's Mome
Emeraeney Room/OutpaSlent Deatl on Arriv;l Nursing Home/LOng-Term Garc Facliity Other(Spedfy)
� 15b.Facllity Nsme(If not Insilt�tlon,give sereet antl number7 •ISC.Clty Or Town,Sta[e,antl Zlp Code 15d.County of De�ih
� � York Hospitai York,PA�7405 York
/ � 16a.Methed of DlsposiHon � Burlal Crem�t�on 16b.Daie of Disposition 16c.Place of Disposl[lon(Name Of cemeiery,crematory,or o[her place)
�(/ �Femov�l 1rom Stste �Do�atlon
� Other(Specify) Jenuery�5,20�3 HollinperCrematorium ,
� 16E.Locatlen of Dispoaltlen(City or Town,State,�ntl 21p) 17a.Sig�ature of Fvnsr icw Lit ee or Person In Ch�rge of Intertn�ni 17b.Llcense Number
Mt.Hoily Springs,PA'17065 �j� �
L/ FD-O'12984L
17c.Nsme antl Complete AOdress ef Funeral Fseilicy
�g Fogelsanger-Brickar Funnrai Home��2 W King St.PO Box 336,Shippensburg,PA'17257
m 18.DeceEenYs Ed�eatlon-Check the box that bestdeseribes the 19.Decetlent of Hlspanic Orlgin-Check che 20.Decetlmt's Race-Check ONE OR MORE races eo indlute what
highest Eegree or leval of school wmpleted at!he time of death. boz ch�t beaC tlescribes whether ihe Escedent the tlecetlent considerctl hlmsNf or herself to be.
[] Hth grade or lezs is Sp�nish/Hlspanl4L�iino. Cheek M�"NO' ]�WhiYe � Korean
[] No diploma,9Sh-12ih arade . box if tlecedent Is not Spanish/Hfspanic/LaHno.� O g�ack or Afrlun Am�fican Q Vletnamese
]$[High school gred�aate or GED mmpleted �No,not Spsnish/Hispenic/latino 0 American Intltan or Alazka NaHve �Other Asian
� Some college credit,but no degree �V�s,Mezican,MeKlon Amerlcsn,Chlcwno Q Aslan Indlan � Nstiv�Hawalia�
Q Asseclate degree(e.g.AA,AS) Q Yes,Puerto Riun Chlnese
[]'Bachelor's tlegree(e.g.BA,AB,BS) �Ves,Gub�n O Fili ino �Guamanisn or Chamorro
Q Marter's dogree(t.g.MA,M5,MEng,MEtl,MSW,MBA) �Yes,other 5 O P . Q Samoan
Q DoROraie(e. PhO,EtlD P���sh/Hispanic/La[ino 0)apanese �OGher Paclflc Islentle�
g. )or Professionai degree �SpeeHy) 0 O[her(Spacify)
.MO ODS DVM LLB JU
21.Decedmt'e Single Rsce Self-Dezignatlon-Che[k ONLY ONE io indlute whst the decetlent consitleretl himself or herself to be. 22a.DecedenYS Usual OccupKlon-Intllcace type of work
�Wh�K Q�+Panese �Samoan ' done tluring mosc of working 114e. DO NOT USE NETIFED.
�Blsck or Airican Americsn �Korean 0 Othsr Pactfic Isl�ntl�r BaKender
� 0 AmeNCan Indian or Alaske NsYlve �Vlein�mese 0 Don't Know/NOf Sure
� �Asian InCian - 0 Other Aslsn �qefused 22b.Klntl of Business/Industry
.a �Ghlnese 0 N�tive H�wallan �Other(SpecNy)
� O Fllipino . �Gvamanian or Chemorro Men's Club
ITEMS 23a-23tl MVST BE COMPLETED 23a.Date Pronouncetl Deatl(MO/Dry r 23b.SlgnsNre of Person Prono�ncing DeaSM1(Only when applicabi6) 23c.�icense Number
BY PERSON WNO PRONOtJNCES OR
, CERTIFlFS OEATH
23d.Dotc Signed(Me/DSy r) 24.Time of Dea2h
7:15 AM zs.w.,�nea��ei�..",rt,er o�co�o.,e�eo��s�ceaz ]� Yes Q No
� GAUSE OF DEATH Approzimstt
26.PaK 1. Enter fFia cheln ot sventa-dlsesses,fnj�rles,or compllc�tlo�+s-that tllrecHy c��sed ihe tleeth. DO NOT enter terminal�veniz such as certllee arrest Intervel:
rcspfrafory arrest,or ventricvlar flbrtllation withouf showi'rg tM1e etiology. DO NOT ABBREVIATE. Enter only one c��se on a Ilne. Add stldiFlonal Ilnes if necesssry � O�set to De�th
IMMEDIATE CAUSE ---> . Blunt Force Head injury '10 d8Y5
(Final a�aeese or conaltlon - Due to(or.s a eonsequence o�: i
ros�slting in tlea[h) � �
_ p. ulnrcstra�ned Reer Seet Passenger
Sequentlally Ilst condltlons, _ Due to(er as a consequenea of): • �
�f+�v,��•dn+a eo cne�.�.e � Veh{cle Struek in RI h i
IiSted on Ilne a. Enter the C. 9 t$IdB
UN�ERLYIN6 fAUSE D�e to(or�s s conaequence o�: '� ,
(dlsease or I�jury[haf _- . �
� lalciated the svenb r�s�lting tl. � �'{
�'y In death)LAST. Due to(or as a eenaequence ofl:
/ `
s 26.Pa�t 11. En[er other I ifl [ dit4q t Ib H c tl -th b�t not resulting tn che�nderlying cavse give�In Part� 2�.Was an auCOpsy performed7
�
+ ves O No
zs.we�e e�con�y ti�a�ng:a�enabie
� eo w�,.Pi�ce me w�ae or d�a:n�
� Yes No
29.If Femai�: 30.Ditl Tobacco Use Co�tribute to Death7 31.Mpnner of DeaGh
.� � Not pregnant wlthln past year �Yes Q Probebly � Nafura� � Homicide
� Pregnanc at iime of death �No � Unknown � Accitlent
°m' � Nof pregnent,but pregnant wlthin 42 dsri of deatF � � Per+tling Invesiigatlon
j'] Not pregnant,b�t pregnrnC 43 days to 1 yeer b�fore tleefh 3Z.Dste of In u (Mo Day/vr 5 0 S�ICide �Co�ld not be determined
J ry / )( pell Month)
� Unknown If pregnanC wlfhin the past year 33.Tlmp'YtT in)ury
December 3�,20�2 Approximatei �2:�5 AM
34.Place o1 In)�ry(e.g.home;consfruction slfe;farm;acliool) 35.Locatlon of I�J�ry(Street and Number,City,State,Z�p CoLe)
Street Intersection of E McKinley St&Cleveland Ave,Boro of Chembersburg,PA�720
36.In)ury ei Work 37.If T�anspo�taSion In)ury,Speclly: 3B.Describe Mow InJury Ocevrretl:
p ves O o�weyoPeracor p v�d.sor�m Unr�strained Rear Seet Passanger of Struck vehicle
�No ]�Vass�nger � Ofher(Specffy)
39e.Certifler(Check only one):
w �Certifying physlclen-TO the best of my knowl�dge,tleaih ocwrred tlue fo the ceuse(s)end manner sietetl
. 0 Prono�ncing&CerHTying physlclen-To che besf of my knowledge,deeth occurred aC[he time,dste,and plece,antl tlue co ihe c se(s)antl manner statetl
]$[Medlcal Examiner/C�Or.�o.sner-On ihe basis of exemin�tlon,end/or InvesHgatlon,In my opinlon,deech occurred at[he tlme,tlate,and place,entl d�e to the cause(z)�nd manner scatetl
Slgnac�re of certlfl�r: "///w.��,v//�� Tcle of certlfler: CO�OnCf Llcense Number•
39b.Name,Atldress end 21p Cotle of Person Completing Cause ot Desth(Item 26) 39c.Oefe Slgned(MO/Day/Vr)
Mr.Jeffrey R Conner 1497 loudon Roed,Chambersburg,PA�7202 - January 14,2D�3
�oy a0.Regiscrar's Dirtrict N�mb/er AS.ftegisfr sture � 62.R Isfrar Flle Date Mo/Day r)
� � � �/� �
43.Amentlments
O5
. a
2
08'18896 H305-333
DlaposlNon Permii No. REV 07/2011
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RENUNCIATION �� �-; �� __-, �
:-� <_� __J
.�� �..
. �:_.
REGISTER OF WILLS -,, `Y�
,i+ . L,� '- ..
�� b e r � ce �d� COUNTY, PENNSYLVANIA "
� S �✓t � � ���'Y'
Estate of a. � C , De�eas��
, }
I, C�-'� 0� ( V � � � , in my capacity/relationship as
(Print Name) �,
iM� 't" 1'IG� of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
�� �C�tY'
�
��k�e� h�- ��. � � �3 - �- - �
(DateJ ($' e)
� � ��� ' ����
(Street Address)
� � P� � 1�
(c,ry,state,z;)
Executed in Register's Office Executed out of Register's Office
Sworn to or affirmed and subscribed Before the undersigned personally appeared the
before me this day party executing this renunciation and certified
of , that he or she executed the renunciation for the
purposes stated within on this��7�` day
of SP(�}�f tr��� , �o I 3
Deputy for Register of Wills Notary blic
My Commission Expires:
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
COMMONWEALTH OF PENNSYLVANIA
Notadal Seal
Mgela M.Miller,Notary Pub�k
Form RW-06 rev. 10.13.06 Qty of Harrisbury,Dauphin CAUnty
My Commisslon Expires Oct.15,2014